ACEP Says Basing Coverage on Final Diagnosis Compromises Care for Patients and Violates a Federal Law

Health plans and state Medicaid officials are denying coverage for emergency care, based on misleading results generated by a research tool not designed for that purpose, according to the research designer Professor John Billings of New York University’s Wagner School of Public Service. There are no alternative sources of medical care for these patients, according to the nation’s emergency physicians, and it violates the federal prudent layperson standard by basing coverage on the patient’s final diagnosis, which a physician does not know at the time of triage.

Professor Billings said his publications describing his tool and its use explicitly state that it is not intended for use in individual cases as a triage tool or as a mechanism to determine whether emergency department use is appropriate.

“The tool was developed to evaluate the performance of the primary care delivery system and to assess the effect of interventions to improve primary care services,” said Professor Billings who is Director of the Wagner School’s Health Policy and Management Program. “It produces a probabilistic estimate for a broad range of diagnoses as to whether patients visiting an emergency room with that diagnosis could have been treated in primary care setting or the condition was potentially preventable/avoidable with timely and effective ambulatory care.”

In response to budget crises, state Medicaid officials in many states have been using the “Billings algorithm” to deny coverage for emergency department visits based on final diagnosis discharge codes, rather than the symptoms that brought patients to the emergency department. For example, a patient with chest pain, a possible indicator of heart attack, may be discharged with a diagnosis of heartburn, a non-urgent condition.

“A physician does not know the diagnosis when the patient walks in,” said Dr. David Seaberg, president of the American College of Emergency Physicians. “This applies 20/20 hindsight to possibly life-threatening conditions in violation of the national prudent layperson standard designed to protect patients’ health plan coverage of emergency care.”

The prudent layperson standard was codified into the national health care reform law, the Affordable Care Act, in 2010. It also was included in the Medicare Balanced Budget Act of 1997.

The state Medicaid office in Washington State has developed a list of more than 500 diagnoses, without medical input from physicians in the state, which have been deemed “nonurgent” for Medicaid emergency patients, including urinary tract infection; acute bronchitis; and every kind of sprain, which is a diagnosis made after an X-ray to determine whether there is a fracture. The state has determined it will not reimburse for any of these diagnoses. In addition to Medicaid patients, this ruling will affect thousands of Medicare patients who are also Medicaid beneficiaries in the state.

“If health plans and state Medicaid directors are successful, Medicare and private health insurance plans will follow suit,” said Dr. Seaberg. “Many non-urgent diagnoses begin with symptoms that could indicate life-threatening emergencies, such as lower back pain that could also indicate a rupturing aortic aneurysm. No patient should ever be in the position of having to diagnose himself. The irony is, just as the Affordable Care Act will add 16 million more patients to Medicaid, that coverage is being eroded. What kind of health insurance does not cover potentially life-threatening medical conditions?“

“Use of the emergency department for minor conditions may be rational and appropriate if a patient has no other source of care,” said Professor Billings. “Moreover, assessment of urgency by patients can be problematic, and labeling emergency use for primary care treatable conditions as inappropriate may misallocate responsibility to the patients themselves who are often not well-suited to judge need or urgency of care.”

The American College of Emergency Physicians over the past several years has taken issue with numerous health plans, such as Excellus Blue Cross/Blue Shield and Univera Healthcare in New York, regarding the misuse of this formula to assess necessity of emergency department use.

Emergency physicians fought for nearly 20 years for recognition of a national prudent layperson standard. It was applied to Medicare plans in 1997, and applied to nearly all health plans in 2010 with the passage of the Affordable Care Act. The prudent layperson standard requires health plans to cover visits to emergency departments based on an average person‘s belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis. It is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition.

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.